What to do??????????secretions.....

Specialties Hospice

Published

Ok, i've only been back in hospice for 3 months, but I have questions...

10 yrs ago, when I did hospice, our agency had a portable suction setup so should a patient be unable to handle secretions, we could suction their oral airway...So, last night when the assisted living facility for my end stage alzheimers patient called and said "she has brown secretions dripping from the side of her mouth," I called my DME provider, went out with a bulb suction, cleaned her mouth with bulb suction...waited for suction, got machine, used yankers...situation resolved....Called MD this morning, got an order for scopolamine patch.....

Called my administrator to let her know about the fiasco with the suction setup delivery (long story, and not important at this point...it got done); she said I should have only done bulb suction (patient still with audible expiratory rhonci), with yankers, airway was cleared..... And when I talked about the scopolamine patch, she said "if it's not a problem to get it today, that is fine, but i would wait until the comfort pack gets there on monday." *****frankly, i'm trying to offset another middle of the night call********

She said suctioning is for people that are actively bleeding from the oral cavity, not for secretions... It's not like I tried to intubate the patient, just wanted to clear her mouth. I don't want to do the wrong thing, and I was called by the assisted living facility to clear her oral cavity. I don't want to irritate my manager, but I want to do the right thing for my patient...***her RR was 24-26, and was 16-18 after yankers.****

Maybe i'm just having trouble adjusting to hospice from the critical care nursing setting. I mean, the assisted living place can't even give medication rectally, let alone use bulb suction (so they will be calling me out for that)...

What do you all think? As for the scopolamine patch, I was following the logorhythm from the hospice pharmacia book that we use.

Any input is greatly appreciated. I mean, isnt' it about treating the symptoms, airway clogged with secretions = clear airway.....

Any input is greatly appreciated. I just don't want to have to field calls all through the night when an assisted living facility is telling me a patient is in distress, and I don't want my company to be charged for an ambulance being called just to clear her oral cavity.

thanks!!!!

I think of Indiana Jones saying, "It had to be snakes." Nothing worse than juicy secretions. "It had to be secretions."

Specializes in Med Surg, Hospice, Home Health.

all in all, the family was quite thankful that I was there, especially when she was so gurgly and loud...they were calmer as she became more quiet...

linda

i absolutely despise suctioning.

and yet, so many use it readily and eagerly.

many times, the pt isn't even aware of what the ruckus is about.

if families only knew that half of these interventions are more for them than the pt himself....

leslie

Personally, I do discourage suctioning and yes, really many, of not most, of the things we do is for us and the folks. When I carefully and s-l-o-w-l-y review the contents of the comfort kit, day 1 for me. I show the folks the atropine. Explain why it is packaged like eye drops, no, we don't use like eye drops. I call the juicy gurgles, audible respiratory secretions. Sounds clean and clinical. I explain that at the FIRST sound we are going to put 2 drops under the tongue. I then write "secretions" on the vial. When a pt is in a facility, I am matter of fact with all the staff I can talk to. "Call us if pt starts to have secretions you can hear." Even alert pt with lung cancer or other resp problems often benefit from a little atropine. If staff HAS to have a sx machine available. I make them cover it up and put out of pt/folks direct view. Who wants to look at that! I also tell Crisis Care staff that sx is to "vaccuum" out the mouth only. I also tell them a horror story about sx just to decrease their zeal for pulling up a tonsil. The key, newbies, is always think about two steps ahead. If you don't just flat out die, we're gonna get weak. When we get weak, we can't swallow and then we get..juicy.

Specializes in Hospice, Med Surg, Long Term.

We only use suctioning for bleeding problems. We don't use scopalamine patches either. We use levsin and atropine drops. The patches are expensive, levsin is effective, and suctioning is not considered "comfortable". At best, it takes the breath away. But, we all learn by doing or not doing, as the case may be. You stay as long as it takes to take care of the patient and family.

Ana

Specializes in NICU, Educ, IC, CM, EOC.

Used atropine gtts when my Mom was in Hospice and had horrid noisy resps. It was really for me and my sibs, not her; she was peacefully oblivious to the whole issue. The Atropine didn't really help, btw. It just made me feel like I tried something.

Specializes in L&D, Hospice.

very interesting to say the least! where i work we do use suction, some times i feel unnecessarily; i explain to concerned families suctioning a lot of times will increase the secretion production; i have had good results with levsin tabs (we used to use) then we switched to atropin drops; by the time we get to order scopolamin patches the patient often times does not need them any more, but they do work well;

i am surprised to read the use Lasix via nebulizer - i just got the royal ream out for using roxanol via nebulizer - any experience any one?

Specializes in LTC, Sub-Acute, Hopsice.

i just got the royal ream out for using roxanol via nebulizer - any experience any one?

I have used sugar free morphine for nebs for pts with severe SOB. It is useful at times. The last one was a patient with resp. failure at home on a vent. The pharmicist at Hospice Pharmicia was adament about the sugar free part. Although he did say that for the day it would take to get the sugar free morphine there we could use the Roxanol, but had to change the neb set up after each use. I think that it worked well for this paitent, calmed her down, calmed her resp rate (she was able to be with out the vent when awake and sitting up). It was actually a compromise with the (RN nurse practioner) daughter who wanted subqu morphine...a bit extreem and invasive in the opinion of me, the team and the medical director. I used Morphine via neb for patients in long term care prior to working in hopsice and found that it does work...for some. You need a pt that can complete the neb tx, actually takes in the med and blows it off. For someone who is not real compliant with the treatment it is not really worth it. And remember...STAY AWAY FROM THE NEBULIZER WHILE THE TREATMENT IS RUNNING. Had an aide pass out as she was holding the neb for the patient and breathing in the "steam". Thank God she was OK and not allergic to morphine!!!

Specializes in EMS, Clinic, Hospice, Corrections.

Maybe there is some poor comm going on here.. in my hospice we use scop patches and atropine patches, and rarely a Lasix neb, and they do work effectively to manage sectretions

in pts that also have an existing condition that caused problematic increased secretions, in which case we have suction on hand and we use it when pt is "actively dying" just like before.

however it is real important to start early and agressively with the patches and drops, it sounds like you came into a stiutation where sectretions had been allowed to develop untreated for too long, I don't know how effective the patches or drops would be then, have not been in that situation, and perhaps that (how did that situation develop) should be part of your discussion and thought process, and what to change so it would not again. I am puzzled about " actively dying" comment. of course you treat the actively dying, whatever. ok,

I have the advantage of being in a hospice hospital, so care is more continuous, in that situation for us those treatments for us are amazingly effective.

I hope your meeting goes well, don't give up on this too quickly.

Specializes in Hospice, LTC.

Oxyfast as well as MSO4 liquid can be nebulized for respiratory discomfort, they don't work systemically when used via neb and don't interact with the other pain meds. Never heard of the nebulized lasix, however am going to look into it.

Specializes in L&D, Hospice.

is there any literature out there on using oxifast, morphine as well as Lasix via nebulizer????:specs:

Specializes in Hospice, LTC.

Water based Morphine is the best opiod to use for resp discomfort, does not help with secretions and basically is a placebo type effect. Does not increase resp status, only allows pt to "feel" as if it has increased. Oxyfast works, though not as well. Have never tried lasix neb and will be researching this. Also will try to find some info on the opiod nebs.

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